Applicant Conditions

INSTRUCTIONS: Please complete and sign all blanks accurately and legibly to be considered. We may verify all information you provide. A FALSE STATEMENT OR OMISSION MAY RESULT IN DISQUALIFICATION FOR EMPLOYMENT OR DISCHARGE, IF EMPLOYED. The City of Kilgore is an Equal Opportunity Employer. In accordance with the Civil Rights Acts of 1964 and 1991, as amended, the Age Discrimination in Employment Act, and the Americans with Disabilities Act, the City of Kilgore prohibits discrimination in any employment because of race, color, sex, religion, national origin, age or disability. No question on this application is intended to secure information to be used for discriminatory purposes.

Date: *

Position applying for: *

Date you would be available to begin work: *

Check all types of work you will accept: *

Full-time

Part-time

Temporary

Minimum wage requirements:

Have you previously worked or do you currently work for the City of Kilgore?: *

If "Yes", when and what department: *

Do you have any relatives, by blood or by marriage, working for or holding office for the City of Kilgore?: *

If "Yes", please state Name, Department and Relation: *

PERSONAL

First Name: *

Middle Name: *

Last Name: *

Present Address: *

Street/P.O. Box

You will be required to provide your Social Security number to the City of Kilgoreif you pass additional applicant testing.

Telephone Number: *

Mobile Phone Number: *

City: *

State: *

ZIP Code: *

By law, you must be authorized to work in the U.S. in order to be employed by this employer. If you are one of the following, please designate: *

If you are hired can you provide proof of minimum age requirements?: *

Do you have a valid Driver's license?: *

Class: *

CDL: *

Driver's License Number: *

State Issued From: *

Year It Expires: *

Have you been issued a citation for any moving traffic violations within the past three years?: *

Have you ever been arrested, convicted of, pled guilty or no contest to a felony, received probation, deferred adjudication of a: *

If "No" skip to the next question.

First Arrest

Please write down the date, location, what you were charged with and the result here.:

Second Arrest

Please write down the date, location, what you were charged with and the result here.:

Third Arrest

Please write down the date, location, what you were charged with and the result here.:

NOTE: PRIOR TO EMPLOYMENT, APPLICANTS MAY BE INVESTIGATED AS TO CONVICTION FOR PRIOR CRIMINAL OFFENSES.Answering "yes" may not automatically disqualify you, but a false statement or omission of information will. A prior conviction will be considered in relationship to the requirements of the job for which you are applying. Failure to answer the above questions truthfully may result in immediate dismissal if hired. Answers of "yes" to questions will not necessarily disqualify you from employment.

EDUCATION

High School or GED Graduate?: *

School name and city: *

College, Business, Technical Schools Attended.:

Include the name, city, course/major and type of degree or certificate.

Trade School/Vocational Schools:

Include the name, city, course/major and type of degree or certificate.

If requested can you provide a copy of discharge or separation papers:

SKILLS

List any qualifications, skills, on-the-job training or special licenses/certifications you have that may help in determining your qualifications for a position for which you desire to be considered:

EMPLOYMENT HISTORY

(List all jobs beginning with your most recent employer. Use additional pages as necessary)

Employer #1

Employer Name: *

From: *

To: *

Ending Salary: *

Address: *

City: *

State: *

ZIP Code: *

Supervisor's Name: *

Co-Worker’s Name: *

Business telephone number: *

Position/Title: *

Duties: *

Status: *

Reason for leaving: *

Was 2 week notice given?: *

Eligible for Rehire: *

May we contact this employer?: *

Employer #2

Employer Name:

From:

To:

Ending Salary:

Address:

City:

State:

ZIP Code:

Supervisor's Name:

Co-Worker’s Name:

Business telephone number:

Position/Title:

Duties:

Status:

Reason for leaving:

Was 2 week notice given?:

Eligible for Rehire:

Employer #3

Employer Name:

From:

To:

Ending Salary:

Address:

City:

State:

ZIP Code:

Supervisor's Name:

Co-Worker’s Name:

Business telephone number:

Position/Title:

Duties:

Status:

Reason for leaving:

Was 2 week notice giveen?:

Eligible for Rehire:

REFERENCES

List persons other than former employers and relatives who know you well enough to provide information on work ethics and/or character.

Reference #1

Name: *

Address: *

Residence Phone: *

Business Phone: *

Occupation: *

Years Known: *

Business Address: *

Describe your relationship with this person: *

Reference #2

Name: *

Address: *

Residence Phone: *

Business Phone: *

Occupation: *

Years Known: *

Business Address: *

Describe your relationship with this person: *

Reference #3

Name: *

Address: *

Residence Phone: *

Business Phone: *

Occupation: *

Years Known: *

Business Address: *

Describe your relationship with this person: *

Reference #4

Name: *

Address: *

Residence Phone: *

Business Phone: *

Occupation: *

Years Known: *

Business Address: *

Describe your relationship with this person: *

TERMS OF EMPLOYMENT

PLEASE READ CAREFULLY and then select whether or not you agree with the statement.

If I misrepresent or deliberately omit a fact in my application, the City may be justified in refusing employment to me or, if I am already employed by the City, in terminating my employment.

I consent to medical or psychological exams required or requested by the officials of the City as permitted under applicable law.

Depending on the nature of the position I am seeking, I understand the City of Kilgore may conduct pre-employment testing, including an agility test, to assess my qualifications for a particular position. If I require accommodations when the City administers pre-employment tests, I will notify the Human Resources Department, in writing when I submit my application.

If I am offered employment, I may be required to complete a post-offer physical examination at the expense of the City. The job offer is conditional on the results of the medical examination.

I will authorize any physician or hospital to release information that may be necessary to determine my ability to perform the essential functions of my job after I receive an employment offer or during the course of my employment with the City of Kilgore.

I authorize the City of Kilgore, in considering my employment, to make any contacts it deems necessary (including, but not limited to: previous employers, agencies of public record or credit reporting agencies as allowed by the Fair Credit Reporting Act.)

If hired, I can be terminated or transferred to another position with or without cause at any time at the option of the City of Kilgore.

If hired, I agree to a search of any City owned premises assigned to me and I hereby waive all claims for damages on account of such search.

If hired by the City of Kilgore, such employment is for an indefinite period of time and the City of Kilgore can change wages, hours of employment, shift assignments, benefits, positions, and conditions of employment at any time.

This application is the property of the City of Kilgore and will become a part of my personnel file if I am accepted for employment. I further understand this is an application for employment and no employment is being offered and the City of Kilgore, in receiving this application, has made no contract of employment with me and has not in any way guaranteed my future employment.

I shall never construe this application or any other communication, verbal or written, given or made by anyone during the application process for employment by the City of Kilgore as constituting either a contract of employment or a guarantee of employment.

Select whethe you agree or disagree with the above statements.: *

The information in this application is accurate, complete, and is subject to verification by the City of Kilgore. I understand that if I have given any false information in this application or if I have omitted any material facts, I may be disqualified from employment with the City of Kilgore or if hired, I may be discharged immediately upon discovery of such false statements or omissions.

I also understand the City of Kilgore is an "employment-at-will" employer and the acceptance of an offer of employment does not create a contractual obligation upon the City of Kilgore to continue to employ me in the future.

Signature of Applicant: *

Date: *

Reference check authorization: I authorize any person or organization listed in this application and/or by whom I have been previously employed and/or any educational institution I have listed on this application to furnish any information they may have concerning me to the city of Kilgore. I understand the information provided by me may be used for the purpose of determining my eligibility. My previous employers may be contacted unless otherwise noted on this application. I hereby release, indemnify, and hold harmless any governmental entity, employer, or person furnishing information about me.

Signature of Applicant: *

Date: *

Thank you for completing this application form and for your interest in working with us.

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